(19) Successfully Enrolling a Prospective Cohort With Opioid Use Disorder and Serious Infections

Background:
Infectious complications of injection drug use are on the rise, and outcomes among people with opioid use disorder (OUD) and serious bacterial infections (SBI) are dismal.

A prospective cohort study of this population would enable the evaluation of key addiction and infection outcomes, major limitations in prior research. Here we report on the preliminary experiences of enrolling and retaining individuals with OUD and SBI in a prospective observational cohort study.

Objective: To assess the feasibility of enrolling and following a longitudinal cohort of people with OUD and SBI, and to describe baseline characteristics of enrolled participants.

Methods: We enrolled individuals admitted to a large academic hospital in Boston, MA, who had OUD (as assessed by the hospital’s addiction consult team) and SBI requiring >2 weeks of antibiotics as assessed by ICD-10 codes and clinical documentation. We interviewed participants at baseline and at 3-, 6-, 12-, and 24-weeks to assess addiction and infection outcomes. Continuous use of medication for opioid use disorder (MOUD) was defined as use for >12 out of the past 14 days, and patient directed discharges were assessed via timeline follow-back procedures and electronic health record review.

Results: We enrolled 59 individuals with OUD and SBI between12/2019 and 4/2021. Among those due for follow-up, we have retained 74% for 6-weeks, 61% for 12 weeks, and 52% at 24 weeks. Participants were a median of 38 years old (SD=8). They were 79% male, 86% non-hispanic white, 3.4% mixed race, 8% Latinx. The most common infections were bacteremia (64%), osteomyelitis (29%), abscess (25%), and endocarditis (24%), with most people experiencing multiple infectious sources (61%). Baseline demographic and clinical characteristics revealed high prevalence of housing instability (92%), incarceration (34%), recurrent infections (80%), polysubstance use (88%), and recent injection drug use (86%). While nearly all participants were started on MOUD (97%) before hospital discharge, only 39% (8/23) remained on MOUD continuously without interruption or a patient directed discharge.

Conclusions: Enrolling and following a prospective cohort with OUD and SBI was feasible. The high prevalence of adverse social determinants of health and treatment interruptions over 24-weeks illustrates the need for innovative, multifaceted treatment approaches; initiation of MOUD in the hospital is necessary but not insufficient. Active polysubstance use, housing instability, and criminal justice involvement were just some of the adverse experiences that complicated remaining on MOUD. In future studies we will explore the acceptability of mind-body therapies as an adjunctive treatment approach to address pain and distress symptoms experienced by these individuals.

References:

1) Volkow ND, Collins FS. The role of science in addressing the opioid crisis. New Engl J Med. 2017; 377(4): 391-4.

2) Dasgupta N, Beletsky L, Ciccarone D. Opioid crisis: no easy fix to its social and economic determinants. Am J Pub Health. 2018; 108(2): 182-6.

3) Bearnot B, Mitton JA, Hayden M, and Park ER. Experiences of care among individuals with opioid use disorder-associated endocarditis and their healthcare providers: Results from a qualitative study. J Subst Abuse Treat. 2019 Jul;102:16-22. PMID: 31202284.

4) McCarthy NL, Baggs J, See I, Reddy SC, Jernigan JA, Gokhale RH, Fiore AE. Bacterial infections associated with substance use disorders, large cohort of United States hospitals, 2012–2017. Clin Infect Dis. 2020;71(7):e37-44.

5) Barocas JA, Eftekhari, Yazdi G, et al. Long-term infective endocarditis mortality associated with injection opioid use in the United States: a modeling study. Clin Infect Dis. 2020. Epub ahead of print.

Diversity, Equity, and Inclusion: Our study demonstrates the feasibility of enrolling and following a prospective cohort of OUD and SBI study participants. It also demonstrates the high prevalence of adverse social determinants of health, including housing insecurity, unemployment, active polysubstance use and incarceration, as a major cause of MOUD treatment interruptions over 24-weeks of this study. Our study illustrates the need to explore the acceptability of an adjunctive treatment approach to help prevent or decrease the occurrence of treatment interruptions. As a result, in future studies we plan to explore the acceptability of mind-body therapies to address pain and distress symptoms experienced by these individuals.